Vision History

Glasses

Contacts

If you wear contacts, are you interested in hearing about new lens technology?

Yes

No

Do you currently or have ever had any problems in the following areas?

Blurred vision

Yes

No

Burning

Yes

No

Night driving

Yes

No

Distorted vision/halos

Yes

No

Double vision

Yes

No

Dryness

Yes

No

Excess tearing/watering

Yes

No

Eye pain/soreness

Yes

No

Chronic eye/lid infection

Yes

No

Flashes/floaters in vision

Yes

No

Foreign body sensation

Yes

No

Glare/light sensitivity

Yes

No

Head/eye injuries

Yes

No

Illness that affected eyes

Yes

No

Itching

Yes

No

Loss of side vision

Yes

No

Mucus discharge

Yes

No

Redness

Yes

No

Sandy/gritty feeling

Yes

No

Styes/chalazion

Yes

No

Tired eyes

Yes

No

Do you currently suffer from headaches?:

Yes

No

Headache severity:

Mild

Sharp

Severe

Migraine

Time of day headaches occur?

AM

PM

Both

How frequent are the headaches?

Daily

Weekly

Monthly

Where are the headaches generally located?

Top

Front

Back

Right Side

Left Side

Do the headaches include visual disturbance?

Yes

No

Review of Systems

Do you currently or have ever had any problems in the following areas?

Cardiovascular

Chest Pain

Yes

No

High Blood Pressure

Yes

No

Low Blood Pressure

Yes

No

Rapid Heartbeat

Yes

No

Irregular Heartbeat

Yes

No

Swollen Ankles

Yes

No

Vascular Disease

Yes

No

High Cholesterol

Yes

No

Psychiatric

Depression

Yes

No

Insomnia

Yes

No

ADD/ADHD

Yes

No

Anxiety

Yes

No

Alzheimers

Yes

No

Neurological

Dizzy Spells

Yes

No

Head Injury

Yes

No

Headaches

Yes

No

Migraines

Yes

No

Seizures

Yes

No

Stroke

Yes

No

Epilepsy

Yes

No

Parkinson's Disease

Yes

No

Bones/Joints/Muscles

Joint Pain

Yes

No

Muscle Pain

Yes

No

Arthritis

Yes

No

Rheumatoid Arthritis

Yes

No

Gastrointestinal

Crohn's Disease

Yes

No

Heartburn

Yes

No

Ulcer

Yes

No

Acid Reflex Syndrome

Yes

No

Respiratory

Asthma

Yes

No

Chronic Bronchitis

Yes

No

Emphysema

Yes

No

Persistent Cough

Yes

No

Pneumonia

Yes

No

Tuberculosis/TB

Yes

No

Endocrine

Diabetes/Blood Sugar

Yes

No

Treatment:

Diet

Oral

Insulin

Thyroid/Other Gland

Yes

No

Social History

Do you use tobacco products?

Yes

No

Do you use alcohol?

Yes

No

Do you use illegal drugs?

Yes

No

Ears, Nose, Mouth, Throat

Allergies/HayFever

Yes

No

Chronic Cough

Yes

No

Dry Throat/Mouth

Yes

No

Sinus Congestion

Yes

No

Hearing Loss

Yes

No

Lymphatic/Hematologic

Anemia

Yes

No

Blood Clots

Yes

No

Bleeding Problems

Yes

No

Cancer

Yes

No

Integumentary (skin)

Acne

Yes

No

Dry Skin

Yes

No

Psoriasis

Yes

No

Rosacea

Yes

No

Lupus

Yes

No

Genitourinary

Bladder Infection

Yes

No

Kidney Stones

Yes

No

Menopause

Yes

No

Prostate Disorder

Yes

No

Please check if you have ever been exposed to or infected with:

N/A

Gonorrhea

Hepatitis

Syphilis

HIV

Allergies

Food Allergies

Yes

No

Drug Allergies

Yes

No

Environmental Allergies

Yes

No

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

ADD/ADHD

Yes

No

Arthritis

Yes

No

Blindness

Yes

No

Allergies

Yes

No

Cataracts

Yes

No

Cancer

Yes

No

Strabismus

Yes

No

Diabetes

Yes

No

Amblyopia

Yes

No

Heart Disease

Yes

No

Dyslexia

Yes

No

Blood Pressure

Yes

No

Glaucoma

Yes

No

Kidney Disease

Yes

No

Macular Degeneration

Yes

No

Lupus

Yes

No

Retinal Detachment

Yes

No

Thyroid

Yes

No

Vision Therapy

Have any of the following traits been noted? (Check the box if applies)

N/A

Holding reading too close

Reversing when writing ('b' for 'd')

Poor general coordination

Poor posture when reading

Squinting

Reading below grade level

Head close to paper when writing/drawing

Transposing letter/numbers ('12' for '21')

Capable of doing better

Losing place when reading

Using finger to maintain place

Difficulty copying from the chalkboard

Tilting head when reading

Omitting mall words

Close or cover one eye while reading

Vision blur while reading

Short attention span

Move lips on silent reading

Difficulty in school

Poor handwriting

Eyes tired after reading

Reverse when reading ('was' for 'saw')

Bumping into objects

Find reading a chore

PLEASE NOTE: Insurance may cover none or only part of your fees. If we do not accept direct payment from your insurance plan, you will need to pay our office at the time of service and submit your receipt for reimbursement from your insurance company. If your insurance does not pay as expected, you are ultimately responsible for all charges, including copays and deductibles. We cannot be responsible if you are not eligible for benefits. We will be happy to assist you with your claims. Please give any forms to the receptionist.